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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601140
Report Date: 06/10/2024
Date Signed: 06/10/2024 01:53:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2024 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240503102451
FACILITY NAME:HOPKINS MANORFACILITY NUMBER:
415601140
ADMINISTRATOR:WU, LULINFACILITY TYPE:
740
ADDRESS:1235 HOPKINS AVETELEPHONE:
(510) 390-8078
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:88CENSUS: 84DATE:
06/10/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Ricardo AbanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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- Staff do not answer residents calls for assistance timey
INVESTIGATION FINDINGS:
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On 06/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver the findings regarding the allegation received. LPA met with the administrator Ricardo Aban and explained the purpose of today's visit.

During the investigation, LPA conducted interviews with staff, R1, and reviewed pertinent documents. Per interviews it was found there were call button calls made by R1 to the front desk nurses station. The button was pressed about 2 to 3 times during the time frame of 630pm to 7pm by R1 according to the staff person who worked that evening at the front desk. The staff person interviewed indicated that the call button system was working. The front desk staff alerted caregiving staff via facility radio to assist R1 but had no way of confirming that staff did respond timely to assist R1. Per documentation reveiwed and interviews conducted this allegation is substantiated.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. Report is reviewed with Ricardo and copy is provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 14-AS-20240503102451
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HOPKINS MANOR
FACILITY NUMBER: 415601140
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2 (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This regulation has not been met as evidenced by:
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Facility shall develop a paln of correction to ensure this regulation is met at all times. Such plan shall be received by the due date indicated.
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This regulation has not been met as evidenced by: Per interviews and documentation reviewed, it was found that there were confirmed call button pushes between 630pm and 7pm at least 2 or 3 times indicating staff did not meet the calls for assistance of R1 to meet their needs.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC9099 (FAS) - (06/04)
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